HealthInfo Waitaha Canterbury

Advance care planning (ACP)

Whakamaheretanga tiaki wawe

 

Advance care planning (ACP) is the process of thinking about, discussing and writing down your wishes about the type of medical care and treatment you want to receive in the future.

An advance care plan provides a way for you to let any future healthcare team know what is most important to you. Your own priorities, goals and preferences are unique to you and help shape your life. They also impact how you would like to be cared for when you are nearing the end of your life.

You should think about advance care planning before you become seriously ill or injured. It is especially important if you have a terminal condition or are very frail. It is also important if you have strong opinions about how and where you want to be treated at the end of your life.

If you do not have an advance care plan and can no longer make decisions for yourself, your doctor (usually your GP) can create a medical care guidance plan for you.

My advance care plan

Your advance care plan records your preferences and wishes for health care at the end of your life. You should complete your advance care plan with the help of your general practice team or specialist team. It should be the result of your thoughts and discussions with your whānau (family) and loved ones.

Your general practice team or specialist team can explain to you the details of medical treatments for the very ill or injured. They can also talk you through the benefits and risks of these treatments. If you wish, they can lodge your advance care plan on your electronic health record, to be shared with other health professionals if it is needed. For example, if you are seriously injured or unwell and in hospital.

If you make a plan, it is very important that you give copies to your whānau and loved ones. You should also keep a copy somewhere that you and those who live with you know about. For example, with your enduring power of attorney, will and other important documents.

Your advance care plan will only be used if you are not capable of making your own decisions and speaking for yourself. While you are well enough, people will ask you directly.

You might change your mind on some parts of the plan, so reviewing your plan annually is a good idea.

Steps

You can do advance care planning a step at a time and at your own pace. The important steps are thinking about and talking about your wishes, writing them down and sharing them.

There are tools to help at Tō Tātou Reo Advance Care Planning. It is worth finding one that works for you.

Step one – Think about it

Spend some time thinking about:

• what is important to you
• what gives your life meaning
• if there are any treatments or types of care that you would or would not want
• who you would want to make decisions on your behalf if you were not able to
• if there was a choice, how and where you would like to spend your last days
• what is important to you after your death.

Step two – Talk about it

The conversations you have with your whānau and loved ones about your advance care planning wishes are important. Think about who you would like to share your thoughts with. These people might include your:

• whānau
• enduring power of attorney
• friends and loved ones
• general practice team, hospital specialists and healthcare team
• cultural leader or spiritual advisor.

Step three – Write it down

You can download and print the My Advance Care Plan & Guide booklet or ask your general practice or specialist team for a copy. You can also order a printed copy.

Use the My Advance Care Plan & Guide to write down what is important to you and how you like to make decisions. Also write down what treatment you want or do not want and anything else you want others to be clear about.

If you are comfortable using a computer, you can also download an editable PDF that you can fill in then print. To do this, you should save the PDF to your computer then open it with Adobe Reader. If you complete it in a web browser, your information will not be saved.

If you want to share your electronic plan, you should save a non-editable version. This video tells you how to do this.

You do not need to complete every section of the plan – just the parts you want to.

Once you have written down what is important to you and what you want to happen, make an appointment with your general practice team or specialist team. Let them know that your appointment is for an advance care plan discussion. This will help to ensure that the appointment is long enough. It will also give them the chance to prepare before you arrive. Your advance care plan discussion might need more than one appointment.

You may have to pay for an appointment to discuss your advance care plan. Check with your general practice or specialist team.

Your general practice team or specialist team will go through your plan with you and help you complete section 6. Section 6 includes My treatment and care choices and My advance directives.

When your plan is finished and you are happy with it, you and the doctor, nurse or other healthcare professional who is helping you, will need to sign it. This confirms that you are competent to make these decisions. Competency is a legal term meaning you can fully understand the decisions you are making. If you do not get a health professional to sign the form, other doctors might question your ability to make these decisions.

Step four – Share it

Once you have completed and signed your advance care plan, ask your general practice team or specialist team to enter it into your electronic medical record. It will then be available to your healthcare team if you go into hospital, see your doctor or need help from the St John ambulance service.

Give a copy to:

• key whānau members
• your enduring power of attorney (if you have one)
• friends and loved ones.

Step five – Review it

Review your advance care plan regularly to make sure nothing has changed for you. If things change, update your plan.

It is important to share any changes with your general practice team and any people who have copies of your plan.

If you completed an advance care plan using the previous My Advance Care Plan document, it is still valid. If you lodged it in your electronic health record, it will still be there to be used by doctors or ambulance staff if and when it is needed.

If you decide to update your advance care plan, your general practice team or specialist team will help you put it into the new format.

  HealthInfo recommends the following pages

• Te Whatu Ora Waitaha – Deciding about CPR (resuscitation)

  Information about CPR, including what it is and who decides if you will be given CPR.

• Age Concern – Enduring power of attorney information

  Information about enduring power of attorney.

  A pamphlet about enduring power of attorney is also available in te reo Māori.

• Organ donation New Zealand

  Organ donation New Zealand has information that can help you decide if you want to become a donor and how you go about becoming a donor.

Written by Te Whatu Ora Waitaha. Adapted by HealthInfo clinical advisers. Last reviewed October 2024.

Sources

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Review key: HIDLT-326665